Provider Demographics
NPI:1760827117
Name:PETERSON, KEERTI KIRUN (MD)
Entity Type:Individual
Prefix:
First Name:KEERTI
Middle Name:KIRUN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KEERTI
Other - Middle Name:KIRUN
Other - Last Name:NANGIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6210 E HIGHWAY 290 STE 240
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 E WHITESTONE BLVD STE C
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613
Practice Address - Country:US
Practice Address - Phone:512-259-3467
Practice Address - Fax:512-406-7303
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR5795208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX382843602Medicaid
TX382843601Medicaid